"Room of Errors" Saves Lives

Modern medicine can be complicated - relying on high-tech procedures and multiple medications, so it’s no surprise that medical mistakes occur. One study estimates they lead to 400,000 preventable deaths a year and ten times as many serious injuries. To attack that problem, the University of Virginia Medical Center has launched a pilot program called “The Room of Errors.”

“We put all of these safeguards in place, hoping that somewhere every error will be picked up, but we talk about the Swiss cheese model. Every once in a while the holes line up and things get through.”

That’s why UVA created something called the Room of Errors – a simulation lab in which a tiny hi-tech mannequin lies in a crib, attached to the usual complement of monitors. As they enter the room, Dr. Noreen Crane and nurse Kirsten Cooney see plenty of problems.

“So starting with the ventilator not being plugged into a red outlet, the heater not being on, the tidal volume being too large, the rate being too small. The potassium chloride was running at the wrong rate and it also was programmed at the wrong concentration.”

As part of a learning exercise, they and other health care professionals have seven minutes to make notes on what’s wrong. Each identifies about 30 problems, but collectively they spot 54 issues that could put their patient at risk. That effect – dubbed interprofessional education, already a major thrust of UVA’s School of Nursing and Medicine curriculum and now part of the Medical Center’s new training program for nurses, doctors and others -- is also the point.

“Training people from different professions together improves their ability to communicate, problem-solve, make decisions together that benefit the patient.

Dr. Valentina Brashers is Co-Director of the Center for Interprofessional Research and Education, an effort headquartered at the Schools of Nursing and Medicine.

“And the data is very clear that when teams work together effectively, patient safety is improved, quality care is improved.”

And, she says, working as a team eases the stress that many healthcare professionals feel.

“Knowing that there are others that you can work to think with you and share with you their concerns as you work through difficult problems makes care provision a much more enjoyable and rewarding activity. It reduces staff turnover. It creates an environment where we feel like we’re all in it together with the patient.”

So far, clinicians taking part in the exercise have come only from pediatric intensive care, but UVA plans to expand the program to include all parts of the hospital. John Owen – Associate Director of the Interprofessional Center says doing this exercise in the hospital improves the odds of learning.

“When you have training in a classroom and see power point slides and then people get up and never have an opportunity to talk to each other, the transfer of learning is really quite dismal, but it’s been shown that when you move training to the workplace, then the transfer of learning goes up dramatically.”

And Haizlip says feedback from fellow doctors, nurses and other participants suggests the program is a success.

“Yes they want to do it again. Yes, this was a fun way to learn it. Yes they did learn something, and the vast majority have said that they have taken something away from this that they used in the week following in their actual care practice. That’s what we’re looking for.”

In our next report, we’ll tell you about the Situation Room – another UVA initiative that aims to eliminate medical errors and protect the health of patients and the people who care for them.

L-R, John Owen, Julie Haizlip and Valentina Brashers, who run the interprofessional efforts at UVA – theirs is the Center for ASPIRE, Academic Strategic Partnerships for Interprofessional Research and Education.